PEPPERDINE UNIVERSITY GRADUATE SCHOOL OF EDUCATION AND PSYCHOLOGY MFT STUDENT PETITION FOR APPROVAL OF PRACTICUM SITE
Practicum sites not obtained through the MFT Practicum Directory must be approved by your Clinical Training Coordinator (CTC) before hours gained will count toward MFT licensure. To initiate the approval process, students should submit this form together with the accompanying checklist, completed and signed by the individual who will provide the supervision. TO ALLOW ADEQUATE TIME TO REVIEW THE SITE AND TO NOTIFY YOU IF THE SITE HAS BEEN APPROVED, THE COMPLETED PETITION MUST BE SUBMITTED TO THE CTC AT THE CENTER WHERE YOU PLAN TO TAKE PRACTICUM (Rebecca Reed, WLA; Kathleen Wenger IGC and Carla Haberman, EGC.) NO LATER THAN THE END OF THE 9TH WEEK OF CLASSES, PRIOR TO YOUR ENROLLMENT IN CLINICAL PRACTICUM. These procedures have been initiated in an attempt to safeguard students from becoming involved with field placements that may not meet the BBS regulations for MFT licensure and Pepperdine University criteria for appropriate practicum experience. The following is to be completed by the student (please print): Date of request:
_________________________ Student’s ID#: ______________________
Name of Student: (day)
________________________
Telephone: ( (
) ______________ ) ______________ (eve)
Student’s address: _____________________________________________________________ Name of agency:
_____________________________________________________________
Agency’s Address: _____________________________________________________________ Name of proposed supervisor and license held: _____________________________________________________________________________ name license # expiration date Supervisor’s telephone: ( ) __________________________
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To be completed by student (if either question is answered yes, this person may not serve as your supervisor): 1. Are you related by blood or marriage to the person who will act as your supervisor?
YES
NO
2. Do you have a personal relationship with the person who will act as your supervisor which might undermine the effectiveness of supervision?
YES
NO
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date revised: 9/05
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NOTE: This form is to be completed by the agency representative (i.e., clinical director).
PEPPERDINE UNIVERSITY GRADUATE SCHOOL OF EDUCATION AND PSYCHOLOGY CHECKLIST FOR PRACTICUM SETTINGS The following checklist is based on the BBS Supervisor Responsibility Statement, to help the Pepperdine University MFT Clinical Training office determine whether or not a potential field training experience will meet the BBS requirements for licensure and the Pepperdine University criteria for practicum credit.
YES NO
1. The agency under consideration meets the requirements as stated in Business and Professions Code Excerpt From Section 4980.43 (e) (e) (1) A trainee may gain the experience required by subdivision (f) of Section 4980.40 in any setting that meets all of the following: (A) Lawfully and regularly provides mental health counseling or psychotherapy. (B) Provides oversight to ensure that the trainee's work at the setting meets the experience and supervision requirements set forth in this chapter and is within the scope of practice for the profession as defined in Section 4980.02. (C) Is not a private practice owned by a licensed marriage and family therapist, a licensed psychologist, a licensed clinical social worker, a licensed physician and surgeon, or a professional corporation of any of those licensed professions. (2) Experience may be gained by the trainee solely as part of the position for which the trainee volunteers or is employed.
2.
Clinical supervision will be provided in each week where client contact hours are earned and meet the BBS supervision requirements; for every 5 hours of weekly client contact, on average, a minimum of one unit (two hours group supervision, or one hour individual supervision) is required while the student is enrolled in Clinical Practicum. Included in the hours are the following:
a.
A minimum of 2 hours per week of direct counseling with clients for a total of 150 hours over three terms.
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b.
One hour per week of individual supervision OR 2 hours per week of group supervision in groups of 8 or fewer persons.
c.
The remainder of time may be spent in clinically related workshops and training.
3.
The supervisor is a licensed professional, i.e., MFT, Psychologist, LCSW, board certified Psychiatrist. [Note: Educational Psychologists may not supervise MFT trainees.] The following must be true regarding the supervisor:
YES NO
a.
The license is valid, unexpired and has been held for at least 2 years.
b.
There are no disciplinary actions pending that might affect the ability to supervise.
4.
The supervisor has practiced for at least 2 years within the 5-year period preceding supervision. Furthermore, the supervisor:
a.
Has averaged at least 5 patient/client hours per week.
b.
Is sufficiently experienced, trained, and educated to provide competent clinical supervision to MFT trainees.
c.
The student will be offered opportunities to work with couples and families while receiving Family Therapy supervision and training.
5.
The supervisor knows and understands the California laws/ regulations pertaining to the supervision of MFTs and the experience required for licensure as a MFT in this state. The following are some of these supervision issues:
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a.
Ensuring that trainees properly assess, examine, and treat clients. fs.documents
b.
Ensuring that trainees practice within the scope of the MFT license and their competence.
c.
Monitoring the quality of services provided by the trainee by direct observation (audio or video recording, 1-way mirror, or supervisor’s presence in the counseling session). Pepperdine requires that direct observation occur at least twice per semester and at least once during the summer term. Supplementary methods may include review of progress or process notes or records or any other means that are deemed appropriate.
d.
If supervision is provided on a voluntary basis, the agency and the voluntary supervisor will have a written agreement prior to the initiation of supervision which ensures that the extent, kind and quality of counseling performed is consistent with the training, education, experience of a MFT trainee, and that the counseling provided by the trainee will be appropriate in extent, kind and quality. (Write N/A in margin if supervisor is a paid employee.)
e.
Will provide at least 1-week written notice to trainees if the supervisor intends not to certify any further hours of experience. If such a notice is not provided, the supervisor shall sign for hours of experience obtained in good faith where the supervisor actually provided the required supervision.
f.
Will sign a “Supervisor’s Responsibility Statement” prior to the commencement of supervision which states that he/she meets the BBS criteria for acting in a supervisory capacity.
6.
Will sign for licensure only those trainee hours that are within the “dynamics of marriage, family and child relationship counseling.” Effective January 1, 2000, all persons licensed by the BBS who supervise interns and trainees must complete a minimum of six hours of supervision training or coursework every two years. This training/coursework may apply towards the required 36 hours of mandatory continuing education. Supervisors who are licensed by the BBS who have completed a minimum of six hours of supervision training or coursework between January 1, 1997 and December 31, 1999 may apply that training toward the above requirement. Supervisors who commence
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supervision on or after January 1, 2000, and have not met the supervision CE requirement, shall complete the six hours of supervision training and coursework within sixty days of commencing supervision. It is essential that all licensees who are providing supervision at the beginning of the new year complete the mandatory supervision training or coursework no later than sixty days into the new year. The content of the supervision training or coursework is left to the discretion of the supervisor, however, the training or coursework must be taken from a BBS approved CE provider. (The California Therapist, Sept/Oct 1999) I have read the above guidelines and feel that our agency and the supervisor(s) who will be working with the trainees meet the BBS requirements for licensure and the Pepperdine University criteria for practicum credit. Furthermore, by signing below, I understand that the following are true:
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1.
The relationship between the training agency and the student/trainee is that of employer-employee.
2.
The University has not committed to indemnify the training agency against any liabilities incurred by the student/trainee.
3.
The Directory used by students/trainees to locate a training agency is strictly a resource and not a placement service.
4.
The University cannot assure that all students/trainees who seek training opportunities with your agency are enrolled in practicum courses at the University.
5.
The University takes no responsibility for checking whether or not students have obtained professional liability coverage.
6.
Practicum instructors and students/trainees understand that clinical issues raised during practicum class are not to be initiated without first consulting their clinical supervisor at the training agency.
7.
Decisions to include or not include training agencies in the Directory are strictly at the discretion of the University, and notification of these decisions cannot be assured.
8.
Training agencies may request to not be included in the Directory. fs.documents
Print Name __________________________________ Title ____________________________ Signature ____________________________________________ Date ____________________ Agency _______________________________________________________________________ Address _______________________________________________________________________ ______________________________________________________________________________
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PEPPERDINE UNIVERSITY GRADUATE SCHOOL OF EDUCATION AND PSYCHOLOGY MFT PRACTICUM AGENCY INFORMATION (Please print information) Name of Agency: ______________________________________________________________ Address: _______________________________ City: ____________________ Zip: _________ Agency contact person: __________________________________________________________ Degree
License
Title/Position At Agency
Agency Director (if different from above): ___________________________________________ Telephone: (
) ______________ FAX: (
) ______________ email: ___________________
I. Description of Agency A. Type of agency (check one and attach appropriate documentation): Nonprofit/charitable organization Licensed health facility School, college or university Governmental entity Other______________________________ B. Describe the client population and typical presenting problems: _____________________________________________________________________________ _____________________________________________________________________________
II. Supervision provided A. California licenses/certifications held by professionals providing supervision to trainees – check all that apply at your agency: MFT
LCSW
Psychologist
Board Certified Psychiatrist
Notes: 1. Educational Psychologists cannot supervise MFT trainees 2. Supervisors must be licensed for a minimum of 2 years prior to commencing supervision. B. Amount of supervision provided: 1. Individual supervision: _______ Hours per week 2. Group supervision (in groups of 8 or less): _______ Hours per week date revised: 9/05
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Can your agency provide evening/weekend supervision? __________________________________ C. Students at Pepperdine are enrolled in the Master of Arts in Clinical Psychology with an emphasis in Marriage and Family Therapy. Does your agency provide supervision in working conjointly with couples and/or members of a family? Yes No If yes, check the orientation(s) of the supervisor(s): Cognitive-Behavioral Post-Modern/Narrative Psychodynamic/Object Relations Existential Strategic/Structural Humanistic/Communications Solution-focused/Brief Other_______________________________________ D. Is it the agency’s policy to prohibit trainees from working with families (conjointly)? E. Do your supervisors provide supervision from a family therapy perspective? F. Students must receive an average of at least one hour of individual supervision (or two hours of group supervision) for every five hours of client contact they gain. Can your agency provide supervision at this five to one ratio? Yes No
III. Entry Qualifications of MFT Trainees A. Pepperdine students enrolling in Practicum meet or exceed the California State academic requirements for entry into practicum. Is your agency willing to accept trainees who may not have had counseling experience beyond classroom role-playing? Yes No B. Please list any specific requirements for applicants:
___________________________________
_________________________________________________________________________________
IV. Practicum Experience A. Total number of trainee/intern slots at your agency: _______ B. Describe your application procedure: 1. Initial step students take to apply: ___________________________________________ 2. Required application materials: _____________________________________________ 3. Pepperdine students begin Practicum three times a year, as listed below. Circle any of these months that coincide with the hiring periods for your agency, and below each month you circle, indicate an application deadline. If no specific deadline exists, write “open”.
Deadlines:
September
January
April
________
________
________
C. Required length of commitment to agency: _________________ date revised: 9/05
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D. Minimum number of hours required per week (total): _________________ E. Does your agency provide any formal training above and beyond supervision? Yes No If yes, please briefly describe the training opportunities: _________________________________ _______________________________________________________________________________ F. Days/times trainee must be present in addition to normal clinical responsibilities/supervision (e.g., staff meetings, workshops, training): _____________________________________________ G. Using the following scale, rate the amount of time the trainee will spend at each one of the listed tasks. never rarely sometimes frequently most-of-the-time always 0 1 2 3 4 5 ___ Counsel adults ___ Counsel couples ___ Counsel children
___ Counsel families ___ Counsel groups ___ Telephone/crisis counseling
H. Do trainees at your agency ever work off-site, such as in a school-based program, or in private homes? Yes No What sites? __________________________________________________ If yes, what percentage of the trainee’s weekly hours will be earned off-site? __________________
V. Additional considerations A. Does the agency pay trainees? Yes No Amount: $_______________ B. Are there charges/fees trainees must pay? No Yes Amount: $ ___________________ If yes, give reason for charges/fees: _______________________________________________ C. If your agency employs trainees in locations other than your above listed address, please list the cities in which your additional facilities are located. (Note: if the space provided here is insufficient, please attach a separate sheet. Also, if your affiliated facilities go by different names than the above listed agency name, please include that information.) ____________________________________ _____________________________________________________________________________ D. Is the contact person a Pepperdine alumnus? Yes No Is the Agency Director a Pepperdine alumnus? Yes No E. Would your agency accept master's level students who are not yet ready for practicum but who would like to volunteer their services to the agency? Yes No F. Other relevant information: ____________________________________________________________________________________ ____________________________________________________________________________________ Pepperdine’s MFT Clinical Training Department thanks you for your time and effort in providing this information! Please sign and date this form below:
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_____________________________________________________________________________ Name and Title (please print)
___________________________________ Signature
date revised: 9/05
___________________________________ Date
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